Deck 32: Nursing Assessment: Cardiovascular System

Question 1

While assessing a patient who was admitted with heart failure,the nurse notes that the patient has jugular venous distention (JVD)when lying flat in bed.Which action should the nurse take next?

A) Document this finding in the patient's record.
B) Obtain vital signs, including oxygen saturation.
C) Have the patient perform the Valsalva maneuver.
D) Observe for JVD with the patient upright at 45 degrees.

Answer 1

Observe for JVD with the patient upright at 45 degrees.

Question 2

Which information obtained by the nurse who is admitting the patient for magnetic resonance imaging (MRI)will be most important to report to the health care provider before the MRI?

A) The patient has an allergy to shellfish.
B) The patient has a history of atherosclerosis.
C) The patient has a permanent ventricular pacemaker.
D) The patient took all the prescribed cardiac medications today.

Answer 2

The patient has a permanent ventricular pacemaker.

Question 3

The nurse has received the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction.The most important laboratory result to review will be

A) myoglobin.
B) low-density lipoprotein (LDL) cholesterol.
C) troponins T and I.
D) creatine kinase-MB (CK-MB).

Answer 3

troponins T and I.

Question 4

To determine the effects of therapy for a patient who is being treated for heart failure,which laboratory result will the nurse plan to review?

A) Troponin
B) Homocysteine (Hcy)
C) Low-density lipoprotein (LDL)
D) B-type natriuretic peptide (BNP)

Question 5

A transesophageal echocardiogram (TEE)is ordered for a patient with possible endocarditis.Which action included in the standard TEE orders will the nurse need to accomplish first?

A) Start an IV line.
B) Place the patient on NPO status.
C) Administer O₂ per nasal cannula.
D) Give lorazepam (Ativan) 1 mg IV.

Question 6

To auscultate for S3 or S4 gallops in the mitral area,the nurse listens with the

A) bell of the stethoscope with the patient in the left lateral position.
B) diaphragm of the stethoscope with the patient in a supine position.
C) bell of the stethoscope with the patient sitting and leaning forward.
D) diaphragm of the stethoscope with the patient lying flat on the left side.

Question 7

When assessing a newly admitted patient,the nurse notes a murmur along the left sternal border.To document more information about the murmur,which action will the nurse take next?

A) Find the point of maximal impulse.
B) Determine the timing of the murmur.
C) Compare the apical and radial pulse rates.
D) Palpate the quality of the peripheral pulses.

Question 8

The nurse hears a murmur between the S1 and S2 heart sounds at the patient's left fifth intercostal space and midclavicular line.How will the nurse record this information?

A) Systolic murmur heard at mitral area
B) Systolic murmur heard at Erb's point
C) Diastolic murmur heard at aortic area
D) Diastolic murmur heard at the point of maximal impulse

Question 9

The standard policy on the cardiac unit states,"Notify the health care provider for mean arterial pressure (MAP)less than 70 mm Hg." The nurse will need to call the health care provider about the

A) postoperative patient with a BP of 116/42.
B) newly admitted patient with a BP of 150/87.
C) patient with left ventricular failure who has a BP of 110/70.
D) patient with a myocardial infarction who has a BP of 140/86.

Question 10

When the nurse is monitoring a patient who is undergoing exercise (stress)testing on a treadmill,which assessment finding requires the most rapid action by the nurse?

A) Patient complaint of feeling tired
B) Pulse change from 87 to 101 beats/minute
C) Blood pressure (BP) increase from 134/68 to 150/80 mm Hg
D) Newly inverted T waves on the electrocardiogram

Question 11

When admitting a patient for a cardiac catheterization and coronary angiogram,which information about the patient is most important for the nurse to communicate to the health care provider?

A) The patient's pedal pulses are +1.
B) The patient is allergic to shellfish.
C) The patient had a heart attack a year ago.
D) The patient has not eaten anything today.

Question 12

A registered nurse (RN)is observing a student nurse who is doing a physical assessment on a patient.The RN will need to intervene immediately if the student nurse

A) presses on the skin over the tibia for 10 seconds to check for edema.
B) palpates both carotid arteries simultaneously to compare pulse quality.
C) documents a murmur heard along the right sternal border as a pulmonic murmur.
D) places the patient in the left lateral position to check for the point of maximal impulse.

Question 13

When auscultating over the patient's abdominal aorta,the nurse hears a humming sound.The nurse documents this finding as a

A) thrill.
B) bruit.
C) murmur.
D) normal finding.

Question 14

Which action will the nurse implement for a patient who arrives for a calcium-scoring CT scan?

A) Insert an IV catheter.
B) Administer oral sedative medications.
C) Teach the patient about the procedure.
D) Confirm that the patient has been fasting.

Question 15

During a physical examination of a 74-year-old patient,the nurse palpates the point of maximal impulse (PMI)in the sixth intercostal space lateral to the left midclavicular line.The most appropriate action for the nurse to take next will be to

A) ask the patient about risk factors for atherosclerosis.
B) document that the PMI is in the normal anatomic location.
C) auscultate both the carotid arteries for the presence of a bruit.
D) assess the patient for symptoms of left ventricular hypertrophy.

Question 16

After noting a pulse deficit when assessing a 74-year-old patient who has just arrived in the emergency department,the nurse will anticipate that the patient may require

A) emergent cardioversion.
B) a cardiac catheterization.
C) hourly blood pressure (BP) checks.
D) electrocardiographic (ECG) monitoring.

Question 17

A patient is scheduled for a cardiac catheterization with coronary angiography.Before the test,the nurse informs the patient that

A) it will be important to lie completely still during the procedure.
B) a flushed feeling may be noted when the contrast dye is injected.
C) monitored anesthesia care will be provided during the procedure.
D) arterial pressure monitoring will be required for 24 hours after the test.

Question 18

The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor to

A) connect the recorder to a computer once daily.
B) exercise more than usual while the monitor is in place.
C) remove the electrodes when taking a shower or tub bath.
D) keep a diary of daily activities while the monitor is worn.

Question 19

When reviewing the 12-lead electrocardiograph (ECG)for a healthy 79-year-old patient who is having an annual physical examination,what will be of most concern to the nurse?

A) The PR interval is 0.21 seconds.
B) The QRS duration is 0.13 seconds.
C) There is a right bundle-branch block.
D) The heart rate (HR) is 42 beats/minute.

Question 20

While doing the admission assessment for a thin 76-year-old patient,the nurse observes pulsation of the abdominal aorta in the epigastric area.Which action should the nurse take?

A) Teach the patient about aneurysms.
B) Notify the hospital rapid response team.
C) Instruct the patient to remain on bed rest.
D) Document the finding in the patient chart.

Question 21

While listening at the mitral area,the nurse notes abnormal heart sounds at the patient's fifth intercostal space,midclavicular line.After listening to the audio clip,describe how the nurse will document the assessment finding.

A) S₃ gallop heard at the aortic area
B) Systolic murmur noted at mitral area
C) Diastolic murmur noted at tricuspid area
D) Pericardial friction rub heard at the apex

Question 22

When the nurse is screening patients for possible peripheral arterial disease,indicate where the posterior tibial artery will be palpated.

A) 1
B) 2
C) 3
D) 4

Question 23

The nurse and unlicensed assistive personnel (UAP)on the telemetry unit are caring for four patients.Which nursing action can be delegated to the UAP?

A) Teaching a patient scheduled for exercise electrocardiography about the procedure
B) Placing electrodes in the correct position for a patient who is to receive ECG monitoring
C) Checking the catheter insertion site for a patient who is recovering from a coronary angiogram
D) Monitoring a patient who has just returned to the unit after a transesophageal echocardiogram

Question 24

The nurse is reviewing the laboratory results for newly admitted patients on the cardiovascular unit.Which patient laboratory result is most important to communicate as soon as possible to the health care provider?

A) Patient whose triglyceride level is high
B) Patient who has very low homocysteine level
C) Patient with increase in troponin T and troponin I level
D) Patient with elevated high-sensitivity C-reactive protein level